Severe abuse in childhood linked to mental health problems in later life
A systematic review has found strong evidence that severe child abuse is associated with an increased risk of depression, anxiety and post-traumatic stress disorder (PTSD) in adult life.
The evidence that less severe family relationship problems increase the child's vulnerability to mental health problems in adulthood is, however, less conclusive.
The review was restricted to prospective, long-term cohort studies with more than 100 participants where there was an interval of at least ten years between collection of data on family relationships and outcome measures. A total of 23 studies, from 16 cohorts, was included, with a median follow-up interval of 22 years.
Five out of six studies which followed up children who had suffered severe abuse and/or neglect found a significantly increased incidence of depression at follow-up. The one exception was a relatively low-quality study where there may have been a high rate of undetected abuse in the control group. Where measures of anxiety (one study) and PTSD (three studies) were included, a link was also found.
Three studies (two cohorts) found that maternal ‘emotional unavailability' in early life was significantly associated with suicidal attempts in adolescence.
There was also some evidence that emotional unresponsiveness, rejection, family discord and affectionless control increased the risk of anxiety/depression. However, the studies were very heterogeneous, both with regard to relationship and outcome measures, and findings were inconsistent and affected by confounding variables.
According to CBT theory, negative core beliefs about the self develop in childhood, as the child interacts with his/her family, and are subsequently activated by depression.1
Both severe abuse and milder forms of family dysfunction can produce negative beliefs, which belong either to the helpless or unlovable categories. Children with emotionally unresponsive or rejecting parents are likely to develop attachment insecurity and a belief that they are unlovable.
Children of affectionless, hypercritical, controlling parents may compensate for their belief of unworthiness by becoming high achievers, but are at the same time at increased risk of depression.2
GPs are primarily diagnosticians, not therapists. Nevertheless, the process of diagnosis itself may have therapeutic value, by helping patients to understand their problems and empowering them to address them. It is thought that GPs who provide more complex psychosocial explanations are more likely to achieve this.3
I find that, for selected patients, a single, hour-long, ‘family tree' appointment can be a very effective way of achieving a deeper understanding of a patient's mental health problem by placing it within a historical and family context.
Weich S, Patterson J, Shaw R et al. Family relationships in childhood and common psychiatric disorders in later life: systematic review of prospective studies. Br J Psych 2009;194:392-8Reviewer
Dr Phillip Bland